OPINION OF TRUSTEES ______________________________________________________________________________
Complainant: Respondent: ROD Case No:
11-0120 – November 18, 2015
Michael H. Holland, Marty D. Hudson, and Joseph R. Reschini
The Trustees have reviewed the facts and circumstances of this dispute concerning the provision of benefits under the terms of the Employer Benefit Plan.
The Complainant is an employee of the Respondent. The Complainant’s daughter sought medical treatment at the local emergency room on April 22, 2012, complaining of an insect bite to the left hamstring area that was “getting more red and hard.” The acuity level for the visit was rated as 5-non-urgent (lowest acuity level). She was diagnosed with an abscess, given an initial dose of an antibiotic and was given a written prescription upon discharge. The emergency room notes indicated that the initial onset of pain was two days earlier.
The Respondent denied the emergency room charges, stating that the patient’s coverage did not provide for this service when performed for the diagnosis reported. When requested, the Respondent would not conduct an appeal of the denial because the request was submitted after the 180-day deadline for receipt of appeals had expired.
Is the Respondent required to provide benefits for the Complainant’s daughter’s emergency room visit on April 22, 2012?
Positions of the Parties
Position of the Complainant: The Complainant’s daughter experienced acute symptoms at the time of service and there were no alternate facilities available to render treatment. The charges are a covered benefit as provided for in the Employer Benefit Plan.
Position of the Respondent: No position was submitted by the Respondent.
Opinion of Trustees ROD Case No. 11-0120 Page 2
Pertinent Provisions Article III. A (2) (a) of the Employer Benefit Plan states:
ARTICLE III BENEFITS
(2) Outpatient Hospital Benefits
(a) Emergency Medical and Accident Cases
Benefits are provided for a Beneficiary who receives emergency medical treatment or medical treatment of an injury as the result of an accident, provided such emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms or the occurrence of the accident.
Article III.A(2)(a) of the Employer Benefit Plan provides benefits for emergency medical treatment if the emergency medical treatment is rendered within 48 hours following the onset of acute medical symptoms. The Introduction to Article III of the Employer Benefit Plan states that covered services shall be limited to those services which are reasonable and necessary and which are given at the appropriate level of care. The Introduction also states that services that are not reasonable and necessary shall include procedures which can be performed with equal efficacy at a lower level of care.
The Funds’ Medical Director reviewed the file, including the emergency room records, and found that although the onset of the patient’s symptoms began less than 48 hours prior to the visit as required by the Plan, such symptoms would not reasonably require emergency medical treatment. The clinical records indicated the emergency room visit was of the lowest acuity and the medical records did not contain any reference to any extenuating clinical circumstances such as a major hypersensitivity to insect bites that would have increased the level of care. The patient’s symptoms were mild enough that she could have been treated in a non-emergency setting over the next few days. The patient’s symptoms do not meet the acuity requirements of the Plan as determined by either the urgency or the severity of her symptoms. Therefore the charges associated with the visit to the emergency room on April 22, 2012, are not a covered benefit under the terms of the Employer Benefit Plan. The Employer is responsible for any associated charges that are otherwise covered by the Plan and it appears that the Employer has already paid for the physician charges associated with the emergency room visit.
Opinion of Trustees ROD Case No. 11-0120 Page 3
Opinion of the Trustees
Pursuant to Article III.A(2)(a) of the Employer Benefit Plan, the Respondent is not required to provide benefits for Complainant’s daughter’s emergency room visit on April 22, 2012.